<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:panel>
    <div class="row-fluid form-horizontal">
        <form wicket:id="form">
            <fieldset>
                <h1>Hpv bericht maken</h1>
                <div class="row-fluid">
                    <div class="span3">
                        <div class="control-group">
                            <label for="bsn" class="control-label span2">MessageId:</label>
                            <div class="controls">
                                <input wicket:id="messageId" class="form-control" type="text">
                            </div>
                        </div>
                        <div class="control-group">
                            <label for="bsn" class="control-label span2">Labnaam:</label>
                            <div class="controls">
                                <input wicket:id="labNaam" class="form-control" type="text">
                            </div>
                        </div>
                        <div class="control-group">
                            <label for="bsn" class="control-label span2">InstrumentId:</label>
                            <div class="controls">
                                <input wicket:id="instrumentId" class="form-control" type="text">
                            </div>
                        </div>
                    </div>
                    <div class="span8">
                        <div class="controls">
                            <table
                                    class="table table-bordered table-condensed organisatie right">
                                <thead>
                                <tr>
                                    <th class="span1">Barcode</th>
                                    <th>Uitslag</th>
                                    <th>Analysedatum</th>
                                    <th>Autorisatiedatum</th>
                                    <th class="status-download">Verwijderen</th>
                                </tr>
                                </thead>
                                <tbody wicket:id="uitslagenContainer">
                                <tr wicket:id="monsterWrappers">
                                    <td><input wicket:id="barcode" class="form-control input-small" type="text"/></td>
                                    <td><select wicket:id="uitslag" class="form-control"></select></td>
                                    <td>
                                        <div class="input-append">
                                            <input wicket:id="analyseDatum" type="text" placeholder="dd-mm-jaar" size="16"
                                                   id="analyseDatum"
                                                   class="input-small datum datum three-months"/> <a
                                                href="javascript:void(0);" class="add-on"
                                                onclick="$(this).prev().datepicker({ changeMonth: true, changeYear: true});"
                                                title="Datum" tabindex="-1"> <i class="icon-calendar"></i>
                                        </a>
                                        </div>
                                    </td>
                                    <td>
                                        <div class="input-append">
                                            <input wicket:id="autorisatieDatum" type="text" placeholder="dd-mm-jaar" size="16"
                                                   id="autorisatieDatum"
                                                   class="input-small datum datum three-months"/> <a
                                                href="javascript:void(0);" class="add-on"
                                                onclick="$(this).prev().datepicker({ changeMonth: true, changeYear: true});"
                                                title="Datum" tabindex="-1"> <i class="icon-calendar"></i>
                                        </a>
                                        </div>
                                    </td>
                                    <td class="status"><a class="btn" wicket:id="verwijderen"> <i
                                            class="icon-trash"></i>
                                    </a></td>
                                </tr>
                                </tbody>
                            </table>
                            <div class="form-actions btn-bottom right">
                                <a class="btn" wicket:id="uitslagToevoegen"> <i class="icon-plus-sign"></i>uitslag
                                    toevoegen
                                </a>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row-fluid">
                    <div class="span12">
                        <div class="form-actions clearfix">
                            <button class="btn btn-info" wicket:id="verstuurHl7Bericht">Verstuur HL7 bericht</button>
                        </div>
                    </div>
                </div>
            </fieldset>
        </form>
    </div>
</wicket:panel>
</html>
